SFPE Commercial General Liability

APPLICATION FOR
COMMERCIAL GENERAL LIABILITY
Fire Protection Engineers
(This is an application for annual “per occurrence” coverage)

A) Please answer all questions in ink, leaving no blank spaces. PLEASE PRINT OR TYPE
B) The application must be signed and dated.
C) When answering questions, please use a separate sheet of paper if space provided is insufficient.

APPLICANT INFORMATION:

1a) Name of Applicant/Organization to be insured: *

Name of Contact Person (person completing application) (Mr. Ms. Dr.): *

1b) Physical Address:

City:

State: *

Zip Code:

Area Code/Phone Number:

Fax Number:

Email:

Website:

Mailing Address:

1c) Applicant is:

Sole Proprietor

Partnership

Corporation

Other

.

1d) Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?

1e) Any operations sold, acquired, or discontinued in the last five years?

Yes

No

1f) Number of employees:

Full-Time Staff

Part-Time Staff

1g) Financial Information:

	Gross Income	Staff Payroll	Subcontractor Payroll*
Past Twelve Months:	Gross Income	Staff Payroll	Subcontractor Payroll*
Estimate of Next Twelve Months:	Gross Income	Staff Payroll	Subcontractor Payroll*

(*Subcontractors are not covered unless added by endorsement)

2) List Branch Offices and Addresses, if any:

3) Date Business was Established:

4a) Please provide a description of your activities below by showing the percentage of income derived from each and a brief description of each. Use a separate sheet of paper if necessary. (Attach any brochures or fliers, if available).

% Description:

4b) Do you perform any activities off-shore or overseas?

Yes

No

If “yes”, what are the activities performed and do you perform them on a seldom, occasional or regular basis?

PREVIOUS INSURANCE:

5) Please provide prior carrier information for the last three (3) years:

5a) Commercial General Liability LIMITS:

	Expiration Date	Carrier	Policy Number	Policy Type	General Aggregate	Products Aggregate	Per Occurrence	Total Premium
.	Expiration Date	Carrier	Policy Number	Policy Type	General Aggregate	Products Aggregate	Per Occurrence	Total Premium
.	Expiration Date	Carrier	Policy Number	Policy Type	General Aggregate	Products Aggregate	Per Occurrence	Total Premium
.	Expiration Date	Carrier	Policy Number	Policy Type	General Aggregate	Products Aggregate	Per Occurrence	Total Premium

5b) Professional Liability

	Expiration Date	Carrier	Policy Number	Limits	Deductible	Total Premium
.	Expiration Date	Carrier	Policy Number	Limits	Deductible	Total Premium
.	Expiration Date	Carrier	Policy Number	Limits	Deductible	Total Premium
.	Expiration Date	Carrier	Policy Number	Limits	Deductible	Total Premium

5c) Has any similar insurance for the Applicant or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant ever been cancelled or declined or refused renewal?

Yes

No

If "yes", please give details:

LOSS HISTORY:

6a) Have any claims or suits been made during the past ten years against the Applicant, or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant?

Yes

No

If "yes", please provide full particulars:

6b) Upon inquiry of all personnel, is the Applicant, or any employee, manager or owner of the Applicant, aware of any circumstance, incident or situation, which may result in a claim?

Yes

No

If "yes", please give details:

6c) Have all claims and circumstances requiring a response in questions 6a) and 6b) already been reported to and accepted by a current or past Insurer?

Yes

No

ADDITIONAL INSUREDS:

7) Please provide name and address of those requesting to be listed as Additional Insureds. Attach copy of insurance section of contract, if applicable.

GENERAL POLICY INFORMATION:

8) Policy Period Requested:

8a) Proposed Effective Date: +

8b) Proposed Expiration Date: +

9) Policy Limits Requested (Per Occurrence/General Aggregate):

NOTE: Professional Liability must be maintained through our office in order to bind the General Liability. If you wish to bind the $2,000,000/$2,000,000 limit on the General Liability, Underwriters will require the Professional Liability must be at $1,000,000/$2,000,000 limits.

I hereby declare the above statements and particulars are true, and that I have not suppressed or misstated any material facts. At the present time, I have no reason to anticipate any claim being brought against me, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between myself and the Underwriters and shall be deemed a part thereof.

This Proposal Form duly completed, together with any supplementary information, must be signed in ink by the Applicant.
Completion of this Proposal Form does not obligate the Applicant or the Insurer to complete this insurance.

COMPLETE EQUITY MARKETS, INC.
(In California dba Complete Equity Markets
Insurance Agency, Inc. CASL#0D44077)
1190 Flex Court
Lake Zurich, IL 60047www.cemins.com
Toll Free: (800) 323-6234
In Illinois: (847) 541-0900
Fax:(847) 541-0444

LII 301 A (08/09) THIS DOCUMENT MUST NOT BE ALTERED OR DUPLICATED

$100,000/$100,000	$250,000/$250,000	$500,000/$500,000	$1,000,000/$1,000,000
$1,000,000/$2,000,000	$2,000,000/$2,000,000